Local Leaders’ View on Racial and Ethnic Minority Clinical Trials Enrollment

General Knowledge of Clinical Trials

We explored participants’ perceptions and experiences regarding clinical trials. Participants were asked to describe their level of knowledge about clinical trials. Most community leaders said it was a science experiment or a research project. One community leader emphasized the role of clinical trials in tailoring treatments to demographics and stated:

“Clinical trials are more of the practice component of medicine, where you’re trying to figure out what’s going to be the best suited for demographic, age group, ethnicity, and geographical location. And so that’s pretty much the difference between the two.”

Another community leader explained,

“Yes, when I hear clinical trials, I think of experimental drugs.”

One healthcare provider group generally had a more nuanced understanding, seeing clinical trials as opportunities for treatment access. A participant in this group stated:

“Well, I was thinking opportunity. There is an opportunity to receive treatment, or possible cure or treatment for something that could without health insurance, could seem unaffordable, or even with health insurance, sometimes can present an opportunity for something to be affordable.”

A small number of participants had previously participated in a clinical trial. One community leader regarded his experience and how the experience impacted him:

“Well there was not very much to it, I mean I don’t know if you know if you’re looking for whether the pleasurable experience if it just wasn’t a whole lot to it on my end in my participation and I participated specifically because of the fact that you don’t get a lot of people of color to participate in this process so that was my sole motivation to participate because of that.”

A few participants or their family members had participated in a clinical trial. The trials mentioned were ADHD and multiple myeloma. As these participants stated:

“I actually participated in a clinical trial for multiple myeloma. It lasted, I believe, about 18 months.”

“I have been invited to get involved in several others since the completion of the one that I did before. But they were not things that necessarily interested me, so I passed on those.”

Another set of healthcare provider had first-hand clinical trial experience as both participants and investigators, one citing a successful trial for glaucoma treatment:

“I participated in a clinical trial for eye drops for glaucoma treatment. I visited the physician’s office once a week for 6 months to pick up the eyedrops. I documented any side effects on a tablet. The drug went on to be FDA approved”.

Clinical Trial Information Access

Participants in both the healthcare provider and community leader groups expressed diverse perspectives on the availability of information and access to clinical trials, particularly in the context of COVID-19 trials. Some community leaders noted a need for more data supporting the influence of celebrity endorsements on increased vaccination rates among people of color. A community leader stated,

“I don’t know that there is any data out there I would say during COVID a lot of the celebrities who were vaccinated and who were pushing for vaccines were advertising and pushing for it but I don’t like you said I don’t know that there’s any data that supports the fact that more people of color got vaccinated because of that.”

Others highlighted the general public’s uncertainty about clinical trials, citing commercials and social media as sources of information, stating:

“I think a lot of people see the commercials or on TV or social media and they’re not sure what clinical trials are and how they can participate, and how that benefits people generally, but certainly people of color.”

Within the healthcare provider group, opinions varied. Some rely on their alma maters for information, while others consider themselves “unicorns” who independently seek and discern information. One participant stated the following:

“I will bet you to say that say that those of us who are on the phone are probably unicorns and as much that we are our own information source. I would venture to say that the people on this call are readers and they have capacity to design truth from fiction. But that’s not the vast majority of people. We still hold our past regards in high regards as sources of information. We still hold our community folk depending on the work that you do as sources of information. you know we are not a monolith in terms of where our information comes from and how we receive it and discern it but for me you know I’m a reader and I’m also engaged at really high levels around stuff like this so I’m my own source for the most part for information but again I would venture to say everybody on this call is but we are not the norm. Our people still get their information from line and milk.”

Another participant, however, stated that in their community, they received consistent outreach about clinical trial information from advertisements, billboards, and other sources (Table 3). A community leader stated:

“There were several universities in Louisiana that did significant outreach in recruiting different race, sex and age range for clinical trials. They used billboards and advertisements in the churches and things like that to talk about their clinical trials.”

Table 3: Sources from which participants obtained information about clinical trials.

Willingness to Participate

All participants were assessed on their willingness to participate in a clinical trial in general and related explicitly to COVID-19 and their willingness to encourage their patients, family members, or fellow community members to participate. Although many participants stated that their hesitancy was more pronounced than their willingness to participate, others indicated that they needed clarification due to the uncertainty of the results. Some of these remarks included:

“Even though I’m vaccinated [I would say I’m a little hesitant based off of just all the research and information that was put out that wasn’t really clear so I would definitely need more clarity on participating in a trial that was COVID-19 related].”

“It would depend on the type of clinical trial. I would be hesitant due to health issues with my lung.”

“Overall I don’t think so. The reason would be due to the variation in strains. It’s almost seeming as though you got to keep the vaccination. It’s gonna almost become like the flu. How would the trial be beneficial if the strain changes each year?”

“I have personally do not trust the clinical trials process, just because, as someone mentioned before, of history, especially with black and brown people in this country. We have participated in things that have resulted in death or like illness, and nothing was really done about it, and so I would probably not participate. If something happens to me, then I just don’t feel like anyone would really care about that. They would go on to the next person to try to get them to participate as well.”

Despite the hesitancy, some participants identified factors that could increase their willingness to participate, such as a preference for participating in clinical trials related to diseases they are passionate about. A community leader suggested,

“Think if they are able to engage community leaders more to gain trust within the community. Minority communities would feel more comfortable overall. Monetary gifts are important, but I think you run the risk of leaning towards the same populations and bias. If they engage with community leaders more to build that longstanding trust that can be helpful”. Another participant stated that they don’t necessarily agree with participating in a COVID-19 clinical trial but perhaps another disease state that they are passionate about. The participant remarked, “I’m not the biggest advocate for COVID, I would say no. But if it was something that was closer to home, and I cared about such as Alzheimer’s dementia or cancer related. I would be more apt.”

Barriers to Clinical Trial Participation

The focus groups were assessed on trust and barriers to clinical trial involvement. Participants highlighted racism, lack of diversity, and historical events like the Tuskegee experiment as key factors or a lack of trust in not only clinical trial participation but also the healthcare system. Participants expressed feeling ignored or not prioritized in clinical settings, citing historical mistrust and current disparities in healthcare. Access to trial information was also deemed inadequate, with socioeconomic barriers further limiting their ability to participation. Two participants stated:

“Yes, I think you know, a participant mentioned this several times about the Tuskegee experiment and people, of course, our generation, I’m of that generation. That’s very familiar with the Tuskegee experiment, you know, for a lot of us that had a very profound effect on, I think the African American Communities’ Trust of the medical Community, because we were literally experimented on in that respect, and so that I think that colored our view of the medical profession, and its practices for years.”

“I think the fear in the African American community of our past in this country with being subjects of clinical trials unknowingly just, not having favorable outcomes, having disastrous outcomes that affected us or impacted our race in a horrible way. So, and it’s not that long ago we’re not talking over a 100 years ago. We’re talking about within the last, I don’t know 40, 50 years.”

A pharmacy student underscored the perception of racial and ethnic communities not feeling prioritized in clinical settings by stating:

“I feel like a lot of minorities don’t feel prioritized in clinical settings.”

Another learner alluded to participant referenced historical mistrust of Black or African Americans in healthcare. She stated:

“Well, I think it’s just about history, honestly, especially for African Americans. And you know how we were treated back then. So, . I hear a lot about pregnant women and the doctors’ offices, and they would be totally ignored about their symptoms. They will be told that they’re over exaggerating and that they’re really not feeling what they’re feeling.” 

Lack of access to information about clinical trial opportunities was identified as a barrier, with a participant expressing dissatisfaction with researchers’ efforts in ensuring participants’ comfort. These comments included:

“[I think those should be a lead in relative to making people feel at least having a level of ease around the decision that they’re making to participate but I don’t think researchers have done a really good job of letting people know.] I think that’s more of an internal thing relative to IRB etcetera and so you know it’s been my experience that researchers are there to get participants and that’s it and down any other level of comfort that they could or would or should even provide to the participant hasn’t been there thus I think you get a lack of people really interested in trials.”

Additional barriers included the impact of lower socioeconomic status on access to information and the ability to participate in clinical trials. Participants emphasized that basic needs like food, housing, and transportation must be addressed before discussing participation in trials:

“I mean, that’s a that’s a really a question. I’d be answering, seeing of those people who are of color that do participate in clinical trials maybe where they are on the economic scale. because it’s a good point. If your necessity necessities and basic needs are not being met. You don’t even really have the capacity to consider right often, because you’re trying to just make sure that you can get to your next meal so it’s hard to then think about even being a part of some type of clinical trial. so that’s a good point. And obviously, if people don’t have you know, adequate you know, safe and good housing, if they if they don’t have food on their table. If they don’t have electricity running through their house. If they don’t have transportation those are going to create barriers for them to, even because you’re trying to talk to them about a clinical trial and they’re going to refocus making sure to get their lights turned on right or making sure they can have their next meal. So those are valid points, and I’d be interested in seeing. Okay? Well, then is it going to take a lot more than what we could be thinking to make sure that the necessities are being met to even be to have the conversation with them to think about something different than then being able to get the necessity and its necessities it needs.”

Another set of questions assessed barriers to participation in COVID-19 clinical trials. Participants identified a lack of trust, grief, and trauma from the pandemic as significant hindrances. The loss of family members to COVID-19 contributed to hesitancy, with participants expressing the need for informed discussions to alleviate concerns. Safety concerns stemming from the ongoing impact of the pandemic were also noted, indicating the importance of addressing psychological and emotional aspects when promoting participation in clinical trials. Some remarks included:

“Yes, it’s basically the loss that they have experience of family members. I work with a lot of youth and as a part of a program that Well, a part of the program that I direct. We work with youth that have experience lost to Covid, and so I see it. I hear it almost daily. I’ve had Ladies are women that are in my mentoring group that lost their lives of Covid. So, their family members are dealing with it. So, it’s. Basically, I think it’s a good thing to have people to go through the clinical trial. It’s just going to take information because of like, I said, the shock of the shock of some people who have had family members. girls who lost their mothers to Covid so it’s like it’s still that word that is very triggering when they hear it So yeah, but I think that with good information we may be able to get people to, maybe volunteer.”

“I think. Just the safety of it because people have been so. I guess, traumatized by Covid in our neighbourhood, in our, you know and the neighbourhood community like basically it’s scary. It’s still scary, and people are now still going through counselling dealing with grief. It’s a lot, and it’s a lot unknown. But I believe that if some people or well informed you may be able to get a small amount, but I don’t think it’ll be a lot of people, a lot of us.”

Several barriers to clinical trial participation were identified, encompassing transportation challenges, environmental barriers associated with low income, concerns about side effects, lack of adequate incentives, lack of medication adherence, language barriers, limited access to appropriate technology, a lack of understanding about clinical trials, and a lack of trust in the government. These diverse impediments underscore the multifaceted challenges that must be addressed to enhance inclusivity and engagement in clinical research initiatives.

Ethnic and Racial Disparities

Participants across both groups expressed concerns about racial and ethnic disparities in healthcare and research. One community leader highlighted the scarcity of racial and ethic minority representation among researchers and emphasized the impact of having researchers who look like the participants. The perception was that increased diversity among researchers could reduce hesitancy among racial and ethnic minorities to participate in clinical trials:

“Another other thing I think relative to that is the number of people of color that are the researchers but when you have people who don’t look like you asking you to participate in a clinical trial I think that in and of itself breeds a level of hesitancy on the part of people of color so if you have more students of color or researchers of color involved in the clinical and the research process and I think you have you cut down the gap because people have a have A at least an opportunity to see themselves as asking the question and there’s a level of innate trust that you know goes along with seeing a person of color on the researcher side of the Ledger rather than the participant side of legend.”

Participants underscored the importance of addressing disparities, with a community leader citing an instance where information about blood pressure medications for Black or African Americans was lacking due to their underrepresentation in clinical trials:

“Now when my primary care physician and I were trying to determine the best combination of drugs to control my high blood pressure, it was because African Americans don’t participate in the clinical trials, so it took us a while to determine of all the medications that were available.”

A healthcare provider expressed enthusiasm for identifying and discussing racial and ethnic disparities, emphasizing the need for active participation by racial and ethnic minorities to influence interventions tailored to their specific needs:

“The reason I’m so enthusiastic is that we think about racial disparities. It’s incumbent upon us as people of color to participate. If not, we will always be behind when you look at you know hard, drug therapies are always on white males which do not apply to a black female. And so if I don’t pave the way for the next steps for interventions to be better for someone who looks like me, then it does us no good. I mean doctors are essentially experimenting on a black female. When these drug therapies were oftentimes designed for white males that are completely different. Don’t have the same lived experience, don’t have the same level of stress. I could go on and on and on about that. And so that’s why I’m absolutely resounding. Yes, that we have to get involved if we want to see a different outcome. If not the black communities of color are going to be left behind.”

While some participants expressed optimism about addressing these disparities through increased participation, others underscored the enduring impact of historical events like the Tuskegee experiment, they highlighted that understanding and addressing this history is essential for addressing the underlying causes of ongoing disparities.

“I feel like it’s kind of hard to forget the Tuskegee situation. Whoever is going out into the community first has to alleviate the fears surrounding that first. We can’t approach them as if we are just trying to gather more African Americans so that we can have a better “head count” for a lack of a better term. We don’t want the members of the community to think that we are going to get what we need and then forget about them.”

Discussion

The first phase of our project involved hosting two focus groups conducted in various community settings in collaboration with local organizations. The first focus group was designed to identify barriers to enrollment in COVID-19 clinical trials and gauge willingness to receive FDA-approved COVID-19 vaccines or those under emergency use authorization. The second focus group, involving community healthcare providers and leaders, focused on education and training strategies to increase enrollment and improve vaccine uptake.

An essential aspect of our research included training community members as health advisors or ambassadors. Focus group participants included the following types of community workers: pharmacists, physicians, nurses, student pharmacists from Florida A&M University (FAMU), social workers, psychologists, community health workers, community leaders, and faith-based leaders, healthcare workers from federally qualified health centers. Pharmacists, pharmaceutical scientists, student pharmacists, and other health professionals also engaged in the education and training of community workers on topics including, but not limited to, the biology of SARS-COV2, COVID-19 infection, COVID-19 vaccines, the significance of participating in COVID-19 clinical trials.

These individuals, residing in and respected by the community, play a vital role in conveying health education messages effectively. Their cultural knowledge and social consciousness uniquely position them to understand and address their communities’ beliefs, attitudes, and behaviors, thereby contributing to changing perceptions regarding clinical trials and vaccination. One Florida community in Miami observed similar findings in a predominately Black or African American community faced with similar challenges [25].

Our research identified three pivotal themes surrounding perceptions of vaccinations within racial and ethnic minority communities: vaccine accessibility, vaccine hesitancy, and vaccine resistance. These factors collectively contribute to the challenges faced in increasing vaccination rates in this demographic [14]. Understanding and addressing these issues are crucial for developing effective strategies to promote vaccination uptake, particularly in the context of COVID-19.

We aimed to tackle these themes through a community-based participatory research (CBPR) approach. CBPR is a foundational strategy for engaging communities disproportionately affected by racial and ethnic disparities [22]. Overcoming mistrust is pivotal in fostering greater participation, especially in medical research or clinical trials. Proven techniques, including collaborative partnerships and equitable engagement, should be employed to educate and engage citizens facing inequalities in environmental exposure, economic burden, and healthcare access.

Adopting the CDC’s Community-Based Organizations COVID-19 Vaccine Toolkit [23] and The Toolkit for Community and FaithBased Organizations [26] as models for information dissemination and education was a step toward delivering accurate and up-todate information. Employing a community navigator and a trainthe-trainer approach, involving healthcare providers and educators from within the community, is effective in building relationships and understanding communication differences [27, 28].

Our study also explored community leaders’ and healthcare providers’ perceptions and experiences regarding clinical trials, focusing on participating in COVID-19 trials. The findings reveal significant variations in understanding, attitudes, and willingness to participate, shaped by a complex interplay of historical, social, and psychological factors. Participants’ knowledge of clinical trials varied across groups. Community leaders generally viewed clinical trials as science experiments or research projects, with some recognizing their role in tailoring treatments to specific demographics. In contrast, healthcare providers demonstrated a more nuanced understanding, recognizing clinical trials as vital opportunities for treatment access. Despite this, only a few participants had prior experience with clinical trials, with most referencing trials unrelated to COVID-19. This distinction in perception highlights the importance of targeted education to bridge knowledge gaps between healthcare professionals and community leaders, ensuring both groups fully appreciate the potential benefits and risks of clinical trial participation.

A significant theme that emerged was the perception of information availability and access to clinical trials. Community leaders expressed diverse views, with some highlighting the need for more data on the potential impact of celebrity endorsements on vaccination rates among racial and ethnic communities. In contrast, others pointed to the general public’s uncertainty, often fueled by commercials and social media. Healthcare providers also had varied experiences, with some relying on their alma maters for information while others independently sought and discerned information. Notably, one participant mentioned consistent outreach within their community through advertisements, billboards, and other sources, suggesting that information dissemination can vary significantly across communities. The lack of tailored public health messages for racial and ethnic communities may contribute to disparities in COVID-19 knowledge and behavior. Recent studies have found that when participants from racial and ethnic groups were randomly assigned to watch public health videos by a diverse group of physicians, knowledge gaps on COVID-19 symptoms, preventive behaviors, and transmission decreased [29,30].

When assessing willingness to participate in clinical trials, particularly those related to COVID-19, participants expressed more hesitancy than willingness. The uncertainty surrounding trial results was a common concern, reflecting broader anxieties about the unknowns of clinical research. Despite this hesitancy, some participants identified factors that could enhance their willingness to participate, such as a preference for trials related to diseases they are passionate about. Enhancing racial and ethnic diversity in clinical trials and healthcare teams has been shown to improve vaccination rates in racial and ethnic communities by building trust, providing culturally relevant education, and reducing language barriers, thereby improving trial participation [31].

Barriers specific to COVID-19 clinical trials were also identified. The psychological and emotional toll of the pandemic, including grief and trauma from losing loved ones, played a role in participants’ reluctance to engage in trials. Safety concerns, stemming from the ongoing impact of COVID-19, underscored the need for informed discussions to alleviate fears and address the lingering effects of the pandemic. Access to clinical trial information also emerged as a critical barrier. Participants pointed to inadequate outreach and a lack of clear, accessible information about available trials. Socioeconomic factors further exacerbated these challenges, as individuals with lower income levels often struggle to meet basic needs such as food, housing, and transportation, making participation in clinical trials a lower priority [32]. These diverse impediments highlight the multifaceted challenges that must be addressed to enhance inclusivity and engagement in clinical research.

A recurrent theme across both community leader and healthcare provider groups was the issue of trust. Participants cited this distrust as a primary factor deterring clinical trial participation [33]. Additionally, the lack of diversity among researchers was noted as a barrier, with several participants expressing a belief that increased representation of minorities in research roles could help mitigate hesitancy among minorities. Racial and ethnic community leaders felt more comfortable participating in clinical trials led by an HBCU. They all agreed that the long-standing relationships between the community and HBCUs, along with the established credibility of HBCU faculty within these communities, would enhance their willingness to participate in clinical trials.

Despite the prevailing hesitancy, some participants identified factors that could increase their willingness to participate in clinical trials. These included a preference for trials related to diseases they were passionate about and the presence of researchers who reflected their racial or ethnic background. There was also recognition of the importance of active participation by people of color to ensure that clinical interventions are tailored to their specific needs. Participants expressed optimism about addressing healthcare disparities through increased trial participation, though they acknowledged that overcoming the historical and ongoing mistrust would be challenging. The enduring impact of events like the Tuskegee experiment was cited as a reason for the continued disparities in healthcare and clinical research participation [15, 34]. This suggests that sustained trust-building initiatives within these communities must accompany efforts to increase enrollment of diverse populations in clinical trials.

Conclusion

In conclusion, our comprehensive approach, rooted in CBPR and incorporating community engagement, education, and outreach, sought to address the multifaceted challenges of racial and ethnic communities clinical trial participation, vaccine accessibility, hesitancy, and resistance within minority communities. By fostering trust, providing accurate information, and actively involving community members, we aspire to contribute to increased participation in clinical trials, improved vaccination rates, and improved health outcomes in these communities.

Racial and ethnic minority community leaders felt more comfortable participating in clinical trials led by an HBCU. They all agreed that the relationships with the community and the credibility of HBCU faculty would enhance their willingness to participate in clinical trials.

Funding

This project is supported by the Food and Drug Administration (FDA) Office of Minority Health and Health Equity of the U.S Department of Health and Human Services (HHS) as part of a financial assistance award [FAIN] totalling $707280.00 with 100 percent funded by FDA OMHHE/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by FDA/HHS, or the U.S. Government.

Ethics Approval

This study was reviewed and approved by Florida A&M University Institutional Review Board

Conflict of Interest: All of the authors have no conflicts of interest to disclose.

Informed Consent: Informed consent was obtained from all individual participants included in the study.

References

1. Narayanasamy S, Mourad A, Turner NA, Le T, Rolfe RJ, et al. (2022) COVID-19 Trials: Who Participates and Who Benefits? South Med J 115: 256-261.
2. Gwede CK, Quinn GP, Green BL (2016) Highlighting Health Disparities in Racial and Ethnic Minorities and Other Underserved Populations. Cancer Control 23: 323-325.
3. Wheeler SM, Bryant AS (2017) Racial and Ethnic Disparities in Health and Health Care. Obstet Gynecol Clin North Am 44: 1-11.
4. Bravo MA, Anthopolos R, Bell ML, Miranda ML (2016) Racial isolation and exposure to airborne particulate matter and ozone in understudied US populations: Environmental justice applications of downscaled numerical model output. Environ Int 92-93: 247-255.
5. James W, Jia C, Kedia S (2012) Uneven magnitude of disparities in cancer risks from air toxics. Int J Environ Res Public Health 9: 43654385.
6. Landrigan PJ, Raps H, Cropper M, Bald C, Brunner M, et al. (2023) The Minderoo-Monaco Commission on Plastics and Human Health. Ann Glob Health 89: 23.
7. Cushing L, Morello-Frosch R, Wander M, Pastor M (2015) The haves, the have-nots, and the health of everyone: the relationship between social inequality and environmental quality. Annu Rev Public Health 36: 193-209.
8. Willis DE, Andersen JA, Bryant-Moore K, Selig JP, Long CR, et al. (2021) COVID-19 vaccine hesitancy: Race/ethnicity, trust, and fear. Clin Transl Sci 14: 2200-2207.
9. Laurencin CT, Valantine H, Yancy C, Jones CP, Bright C (2021) The COVID-19 Vaccine and the Black Community: Addressing the Justified Questions. J Racial Ethn Health Disparities 8: 809-820.
10. Richard-Eaglin A, McFarland ML (2022) Applying Cultural Intelligence to Improve Vaccine Hesitancy Among Black, Indigenous, and People of Color. Nurs Clin North Am 57: 421-431.
11. Bogart LM, Ojikutu BO, Tyagi K, Klein DJ, Mutchler MG, et al. (2021) COVID-19 Related Medical Mistrust, Health Impacts, and Potential Vaccine Hesitancy Among Black Americans Living With HIV. J Acquir Immune Defic Syndr 86: 200-207.
12. Sina-Odunsi AJ (2021) COVID-19 vaccines inequity and hesitancy among African Americans. Clin Epidemiol Glob Health 12: 100876.
13. Garrick O, Mesa R, Ferris A, Kim ES, Mitchell E, et al. (2022) Advancing Inclusive Research: Establishing Collaborative Strategies to Improve Diversity in Clinical Trials. Ethn Dis 32: 61-68.
14. Okoro O, Kennedy J, Simmons Jr G, Vosen EC, Allen K, et al. (2022) Exploring the Scope and Dimensions of Vaccine Hesitancy and Resistance to Enhance COVID-19 Vaccination in Black Communities. J Racial Ethn Health Disparities 9: 2117-2130.
15. Alsan M, Wanamaker M, Hardeman RR (2020) The Tuskegee Study of Untreated Syphilis: A Case Study in Peripheral Trauma with Implications for Health Professionals. J Gen Intern Med 35: 322-325.
16. Pittell H, Calip GS, Pierre A, Ryals CA, Altomare I, et al. (2023) Racial and Ethnic Inequities in US Oncology Clinical Trial Participation From 2017 to 2022. JAMA Netw Open 6: e2322515.
17. Black Doctor (2024) How Implicit Bias is Keeping Black Americans Out of Clinical Trials.
18. Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, et al. (2015) Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review. Am J Public Health 105: e60-e76.
19. Togioka BM, Duvivier D, Young E (2024) Diversity and Discrimination in Health Care. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2026 Jan.
20. Hoffman KM, Trawalter S, Axt JR, Oliver MN (2016) Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A 113: 4296-4301.
21. Yu H, Bauermeister J, Oyiborhoro U, Morales K, Aryal S, et al. (2024) The relationship between trust in federal oversight of vaccine safety and willingness to participate in COVID-19 clinical trials: a repeated measures study of Philadelphia residents (September 2021 - March 2023). BMC Public Health 24: 2059.
22. McFarlane SJ, Occa A, Peng W, Awonuga O, Morgan SE (2022) Community-Based Participatory Research (CBPR) to Enhance Participation of Racial/Ethnic Minorities in Clinical Trials: A 10-Year Systematic Review. Health Commun 37: 1075-1092.
23. CDC STACKS (2021) COVID-19 vaccine communication toolkit for community-based organizations: getting started.
24. Bateman LB, Hall AG, Anderson WA, Cherrington AL, Helova A, et al. (2022) Exploring COVID-19 Vaccine Hesitancy Among Stakeholders in African American and Latinx Communities in the Deep South Through the Lens of the Health Belief Model. Am J Health Promot 36: 288-295.
25. Paat YF, Orezzoli MCE, Ngan CK, Olimpo JT (2023) Racial Health Disparities and Black Heterogeneity in COVID-19: A Case Study of Miami Gardens. J Appl Soc Sci (Boulder) 17: 190-208.
26. Let’s move!; America’s move to raise a healthier generation of kids : toolkit for faith-based & neighborhood organizations. Centers for Disease Control (CDC).
27. Hoeft TJ, Burke W, Hopkins SE, Charles W, Trinidad SB, et al. (2014) Building partnerships in community-based participatory research: budgetary and other cost considerations. Health Promot Pract 15: 263-270.
28. Andrasik MP, Broder GB, Wallace SE, Chaturvedi R, Michael NL, et al. (2021) Increasing Black, Indigenous and People of Color participation in clinical trials through community engagement and recruitment goal establishment. PLoS One 16: e0258858.
29. Alsan M, Stanford FC, Banerjee A, Breza E, Chandrasekhar AG, et al. (2021) Comparison of Knowledge and Information-Seeking Behavior After General COVID-19 Public Health Messages and Messages Tailored for Black and Latinx Communities: A Randomized Controlled Trial. Ann Intern Med 174: 484-492.
30. Torres C, Ogbu-Nwobodo L, Alsan M, Stanford FC, Banerjee A, et al. (2021) Effect of Physician-Delivered COVID-19 Public Health Messages and Messages Acknowledging Racial Inequity on Black and White Adults’ Knowledge, Beliefs, and Practices Related to COVID-19: A Randomized Clinical Trial. JAMA Netw Open 4: e2117115.
31. Reopell L, Nolan TS, Gray II DM, Williams A, Brewer LC, et al. (2023) Community engagement and clinical trial diversity: Navigating barriers and co-designing solutions—A report from the “Health Equity through Diversity” seminar series. PLoS One 18: e0281940.
32. Peña JM, Schwartz MR, Hernandez-Vallant A, Sanchez GR, et al. (2023) Social and structural determinants of COVID-19 vaccine uptake among racial and ethnic groups. J Behav Med 46: 129-139.
33. Bunch L (2021) A Tale of Two Crises: Addressing Covid-19 Vaccine Hesitancy as Promoting Racial Justice. HEC Forum 33: 143-154.
34. Barre I, Cunningham-Erves J, Moss J, Parham I, Alexander LR, et al. (2023) Motivators and Barriers to COVID-19 Research Participation at the Onset of the COVID-19 Pandemic in Black Communities in the USA: an Exploratory Study. J Racial Ethn Health Disparities 10: 28902899.